Non-operative management of appendicitis in children

Management of acute appendicitis in pediatric patients with acute leukemia: Insights from a single-center study

Acute appendicitis (AA) in pediatric patients with acute leukemia mandates prompt treatment. Diagnosis presents challenges, relying on clinical and radiological assessments, often leading to treatment delays that may disrupt leukemia management. Our study on 14 such cases underscores the pivotal role of swift intervention. While conservative AA treatment may pose no risk to healthy children, our findings mandate the performance of laparoscopic appendectomy within 24 hours of diagnosis. This strategy yielded successful surgical outcomes while ensuring uninterrupted leukemia care. Our experience contributes important insights to the limited understanding of navigating this complex clinical scenario.

Determination of Risk Factors for Nausea and Vomiting in Children After Appendectomy

PURPOSE

This study aimed at investigating the risk factors for postoperative nausea and vomiting (PONV) in pediatric patients undergoing appendectomy.

DESIGN

This is a prospective, descriptive, cross-sectional study.

METHODS

The study involved 163 children aged 5 to 18 years who underwent appendectomy in the pediatric surgery clinic of a tertiary hospital between December 2022 and June 2023. The study data were collected through the patient information form, Baxter Retching Faces scale, and Wong-Baker Faces Pain Rating Scale, which included questions about the descriptive and clinical characteristics of the participants and was prepared by the researcher consistent with the literature.

FINDINGS

A significant relationship was observed between the severity of postoperative pain and the occurrence of PONV in patients with both nonperforated and perforated appendicitis (P < .001). In addition, operative time and the time to the first oral feeding were shorter in patients with nonperforated appendicitis in the non-PONV group (P = .005 and P = .042, respectively) Logistic regression analysis revealed that postoperative pain, family history of PONV and appendix perforation were risk factors for PONV in children with both nonperforated and perforated appendicitis (P < .001, P = .040, and P < .001, respectively).

CONCLUSIONS

In children undergoing appendectomy, family history of PONV, severity of postoperative pain, increased operative time, and increased transition time to oral feeding are risk factors for PONV. Pediatric nurses, who have an important role in the management of PONV, should evaluate patients in terms of PONV risk in the preoperative period within the scope of evidence-based practices and perform pharmacological or nonpharmacological interventions according to the degree of risk.

Acute appendicitis in children: is preoperative hyponatremia a predictive factor of perforation/gangrene? A prospective study

PURPOSE

Distinguishing between perforated/gangrenous from uncomplicated appendicitis in children helps management. We evaluated hyponatremia as a new diagnostic marker for perforated/gangrenous appendicitis in children.

METHODS

A prospective study including all children with acute appendicitis who underwent appendectomy at our institution from May 2021 to May 2023. Medical history and clinical criteria were analyzed. All blood samples were taken upon admission including serum inflammatory markers and electrolytes. Patients were divided into two groups (Group I: uncomplicated and Group II: perforated/gangrenous), and data between both groups were compared.

RESULTS

The study included 153 patients [Group I: 111 (73%), Group II: 42 (27%)]. Mean serum sodium concentration in children with perforated/gangrenous appendicitis was significantly lower compared to children with uncomplicated appendicitis (131.8 mmol/L vs. 138.7 mmol/L; p < 0.001). The ROC curve of preoperative sodium level to differentiate between perforated/gangrenous and uncomplicated appendicitis revealed an AUC of 0.981. The cut-off-value of sodium level < 135 mmol/L identified perforated/gangrenous appendicitis with a sensitivity of 94% and a specificity of 91% (p < 0.001). Predictive factors of perforated/gangrenous appendicitis were: age less than 5 years (12% vs. 3%; p = 0.02), experiencing symptoms for more than 24 h (100% vs. 58%; p < 0.001), body temperature more than 38.5 °C (52% vs. 13%; p < 0.001), a serum sodium level less than 135 mmol/L (90% vs. 6%; p < 0.001), and a CRP serum level more than 50 mg/L (71% vs. 17%; p < 0.001).

CONCLUSIONS

Hyponatremia, upon admission, is a novel, objective biochemical marker that can identify perforated/gangrenous appendicitis in children. We advocate that the assessment of serum sodium level should be added to the diagnostic algorithm in children with suspected acute appendicitis. Surgical intervention in patients with hyponatremia should not be delayed, and non-operative management should be avoided.

Effects of menthol gum chewing on postoperative nausea, vomiting, and length of hospital stay in children undergoing appendectomy: A randomized controlled trıal

PURPOSE

This study aimed to determine the effects of menthol gum chewing on nausea, vomiting, and length of hospital stay after appendectomy in children.

BACKGROUND

Postoperative nausea and vomiting (PONV) can be induced by general anesthesia. Several drugs are available to reduce the risk of PONV; however, their cost and side effects limit their clinical use.

METHOD

This was a randomized controlled clinical trial that included 60 children aged 7-18 years who underwent an appendectomy at the Pediatric Surgery Clinic of a tertiary hospital between April and June 2022. Data for this study were collected via the developed information form, which included participants' descriptive characteristics and bowel function parameters, and the Baxter Retching Faces (BARF) nausea scale. Children in the study group who underwent an appendectomy were given chewing gum and asked to chew it for an average of 15 min, whereas those in the control group received no intervention.

RESULTS

The BARF nausea score measured during the menthol gum chewing period was lower in the study group, and the difference score value calculated after pretest time was higher in the study group, as expected (p < 0.001). Moreover, menthol gum chewing was found to shorten hospital stay by 1 day (p < 0.05).

CONCLUSION

Menthol gum chewing reduced the severity of postoperative nausea and length of hospital stay.

PRACTICE IMPLICATION

Chewing gum can be used as a nonpharmacological method by pediatric nurses in clinical practice to reduce the severity of postoperative nausea and length of hospital stay.

Predicting the Severity of Acute Appendicitis in Children Using Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR)

Introduction

The ability to predict risk of perforation in acute appendicitis (AA) could direct timely management and reduce morbidity. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are surrogate severity markers in infections. This study investigates the use of PLR and NLR as a marker for distinguishing uncomplicated (UA) and complicated appendicitis (CA) in children.

Materials and methods

This retrospective single-center study collected data between January 1, 2014, and December 31, 2020. Children between five and 17 years of age with histologically confirmed appendicitis were included. Cut-off values for NLR and PLR were determined by employing the receiver operating characteristic (ROC) curve with sensitivity and specificity in addition to regression analysis.

Results

A total of 701 patients were included with a median age of 13 years. Out of which 52% of the cohort was female. The difference between the NLR and PLR ratios between UA and CA was significant (p=0.05, Kruskal-Wallis). For UA, the area under the ROC curve (AUC) and cut-off for NLR and PLR were 0.741, 3.80 with 95% CI of 0.701-0.781 and 0.660, 149.25 with 95% CI of 0.618-0.703, respectively. In CA, using NLR and PLR, AUC and cut-off were 0.776, 8.86 with 95%CI of 0.730-0.822 and 0.694, 193.67 with 95%CI of 0.634-0.755, respectively. All were significant with p<0.001.

Conclusions

NLR and PLR are reliable, synergistic markers predicting complicated appendicitis which can guide non-operative management in children.

Comparative Analysis of the Acute Appendicitis Management in Children Before and During the COVID-19 Pandemic

Introduction: Acute appendicitis (AA) is one of the most common emergency surgical diseases in pediatric population. Herein, we aimed to compare the incidence and severity of AA before and during the COVID-19 outbreak. Methods: This multicenter study was conducted in three medical faculty hospitals between the periods of 15 March-30 June 2019 (Group A), and the pandemic period of 15 March-30 June 2020(Group B). We evaluated the clinicopathological characteristics of the patients in each group due to age, gender, serum leukocyte, C-reactive protein, radiological imaging use of postop peritoneal drain and presence of serious complications. Results: A total of 141 patients were identified, 64 in Group A and 77 in Group B. We found higher complication rates in Group B. Fewer patients applied in Group B, but a higher rate of AA was diagnosed. During the COVID-19 period, more patients were admitted with the later stages of the AA and with significant complications. Radiological imaging of patients with appendicitis in Group B showed more severe disease than cases in Group A. Conclusion: Higher rate of perforated and complicated appendicitis in the pandemic period was due to misdiagnosis/delayed diagnosis in primary care centers as a result of fear from contagious coronavirus. While the period of the COVID - 19 pandemic presents difficulties in treating infected patients, we would like to emphasize the importance of a comprehensive assessment and physical examination in children with suspected surgical conditions.

Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19.

METHODS

This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

RESULTS

The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy.

CONCLUSIONS

COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.

Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children

INTRODUCTION

 During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA.

MATERIALS AND METHODS

 Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason.

RESULTS

 A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group.

CONCLUSION

 Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.

Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (Pre-COVID-19), and after its declaration (Post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 Pre-COVID-19; 25 Post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs 19.5%; P = .013), as well as a higher CRP (72.7 ± 96.2 vs 31.3 ± 36.2 mg/dL; P = .042). This group presented with a higher proportion of complicated appendicitis when compared to Pre-COVID-19 (32 vs 7.3%; P = .015). The mean hospital stay was longer in the Post-COVID-19 group (5.6 ± 5.9 vs 3.2 ± 4.3 days; P = .041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

[Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis]

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 pre-COVID-19; 25 post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs. 19.5%; P = 0.013), as well as a higher CRP (72.7 ± 96.2 vs. 31.3 ± 36.2 mg/dL; P = 0.042). This group presented with a higher proportion of complicated appendicitis when compared to pre-COVID-19 (32 vs. 7.3%; P = 0.015). The mean hospital stay was longer in the post-COVID-19 group (5.6 ± 5.9 vs. 3.2 ± 4.3 days; P = 0.041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

Incidence and risk of sepsis following appendectomy: a nationwide population-based cohort study

Appendectomy is a frequently performed surgical procedure; however, long-term consequences have not been fully explored. We used a nationwide population-based cohort to determine whether patients undergoing appendectomy are at an increased risk of sepsis. Overall, 252,688 patients undergoing appendectomy and 252,472 matched controls were identified from the National Health Insurance Research Database in Taiwan. A propensity score analysis was used for matching age, sex, index year and comorbidities at a ratio of 1:1. Multiple Cox regression and stratified analyses were used to estimate the adjusted hazard ratio (aHR) of developing sepsis. Patients undergoing appendectomy had a 1.29 times (aHR: 1.29; 95% confidence interval [CI], 1.26-1.33) higher risk of developing sepsis than those not undergoing. Patients aged 20-49 years had a 1.58-fold higher risk of sepsis in the appendectomy cohort (aHR; 95% CI, 1.50-1.68). Also, having undergone appendectomy, patients had a higher likelihood of sepsis, regardless of sex and with or without comorbidities. Patients with <1 year follow-up showed a 1.98-fold risk of sepsis in the appendectomy cohort. Patients with 1-4 and ≥5 years follow-up showed a 1.29 and 1.11-fold risk of sepsis, respectively. Future research is required to elucidate the possible immuno-pathological mechanisms of these associations.

Risk of irritable bowel syndrome in patients who underwent appendectomy: A nationwide population-based cohort study

BACKGROUND

Appendectomy is one of the most common surgical procedures; however, the possible long-term consequences have not been fully explored. The appendix has been associated with microflora of the gut and immune functions. However, literature examining the relationship between prior appendectomy and the risk of irritable bowel syndrome (IBS) is lacking. The aim of this study was to evaluate the risk of irritable bowel syndrome for patients who underwent appendectomy by using a nationwide longitudinal population-based cohort.

METHODS

Data from this study was collected from Taiwan's National Health Insurance Research Database (NHIRD), a population-based database. We identified 12,760 patients who underwent appendectomy between January 1, 2000 and December 31, 2012. A total of 9236 patients who had appendectomy (case group) were randomly matched with 9236 patients who had not undergone appendectomy (control group) in a ratio of 1:1 by means of propensity scores. The hazard ratio (HR) of IBS was calculated by multiple Cox regression. Furthermore, sensitivity test and stratified analysis were performed.

FINDINGS

The incidence rate of IBS was 51.30 per 10,000 person-years in patients having appendectomy, more than the 35.28 per 10,000 person-years in patients not having appendectomy. Patients who underwent appendectomy had 1.46-fold risk of IBS compared to patients not having appendectomy (HR, 1.46; 95% CI, 1.24-1.72). Stratified analysis revealed that the higher HR of 1.55 (95% CI, 1.18-2.04) in patients <40 years old, and particularly within the first 5 years follow-up period of undergoing appendectomy. In addition, patients diagnosed with fibromyalgia had a greater risk of suffering IBS after appendectomy (HR, 1.41; 95% CI, 1.04-1.92).

INTERPRETATION

Patients with appendectomy have a higher incidental risk of IBS than the control population. The risk is higher for patients under 40 years old and those who received appendectomy within 5 years. Physicians could take this into consideration for treatment plans of patients who have underwent this surgery. Further research on the pathogenesis of this association is required.

FUNDING

This work was supported by grants from the Ministry of Health and Welfare, Taiwan (MOHW108-TDU-B-212-133004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 108-2321-B-039-003-), Tseng-Lien Lin Foundation, Taichung, Taiwan, and Katsuzo and Kiyo Aoshima Memorial Funds, Japan.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.